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e5oun e5 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3` o / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �a •C��iFORN�� ° COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY � 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � 7 PERMANENTLY C ED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT �� 6 TEMPORARYSITECLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) C)b 7 DB R FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE _ <;�'- CA SZ s ✓ BOX TO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 71 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS ST TION 2 DISTRIBUTOR RESEIRVATDION #OF TANKS ITE E.P.A. 1.D.#(optional) FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) i PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH A EA CODE ROPERTY OWNER INFORMATION• MUST BE COMPLETED INAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADD SS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION G &1 t% MAILING OR STREET ADDRESS• ✓ box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ �4 l4�- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate I_ tSELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND L_J 5 LETTER OF CREDIT 6 EXEMPTION L] 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.71 III. THIS FORM.HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTI NI# FA aa (- LOCATION CODE -OPTIONAL ___1CENSUS TRACT#_-OPTIONAL—_ SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12 e,) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A-R6 v